Flu on CallTM National Network of Telephone Triage Lines Demonstration Pilot

Form Approved

OMB No: 0920-1026

Exp. Date: 07/31/2017

Management Guidelines for Adults (≥18 years) or Children (2-17 years) with Possible Influenza-Like Illness

(For Use by Poison Centers during 2016 Flu on Call™ DEMONSTRATION PROJECT)

These guidelines were developed for use only by physicians and those under their direct supervision, not for use by general public, to help clinicians participating in the 2016 Flu on Call™ Demonstration Project as they conduct telephone triage and provide advice to callers (or their caregivers) regarding seeking medical care for an influenza-like illness. The guidelines can be used regardless of whether or not the person has been vaccinated for influenza. Callers (or their caregivers) who may have potentially life threatening signs and symptoms (SEE BELOW), such as unresponsiveness or respiratory distress should be instructed to dial 911. These guidelines do not provide guidance for other medical conditions nor are they intended to substitute for professional medical judgement and advice.

1. Phone Etiquette: Always answer the Flu on Call™ line as follows:

   1. “Thank you for calling Flu on Call™, my name is _______________. I am a (Title; such as RN, Pharmacist, Medical Doctor, or Medic). How can I help you?”

2. Start Triage and Evaluate for Life-Threatening or Urgent Medical Conditions

   1. “Are you ill, or caring for, or calling for someone who is ill?”

   2. If No: If caller needs information only, provide information using the VisionLink database and other sources for relevant local public health information.

   3. If Yes to a., evaluate for life-threatening emergency medical conditions and advise to call 911 or go to ED if appropriate using standard poison center protocol.

   4. If Yes to a. (and not determined to have life-threatening condition according to standard protocol), ask “What is the age of the person who is ill?”

      • <2 years old – Recommend they be evaluated by a medical provider. Do not proceed with triage. See Section 8. Referral to Medical Provider

      • ≥2 years old - Proceed with triage

3. Screen for influenza-like illness (ILI)

   1. Ask: “What are the person’s symptoms?”

   2. Using the answer to above, does the ill person have ILI as defined below? If fever or feverishness or the additional symptoms below were not mentioned in response to the question about symptoms, these will need to be asked individually.

      • Fever (>100.0°F / 37.8°C) or feverishness

        1. What was the temperature and when measured? If unable to measure temperature, is patient experiencing shaking chills? Does (s)he feel very warm to touch? When did the fever/feverishness start? Was fever reducing medication given? If yes, how long ago?

        2. NOTE: It’s important to note that not everyone with influenza will have a fever. Lack of fever may be more common in older patients, or if the patient has received antipyretics

      • AND at least one additional symptom: cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue.

   3. Some people with influenza may have vomiting and diarrhea, though this is more common in young children than adults. Onset of symptoms is often abrupt.

   4. The likelihood of influenza depends on the frequency of influenza in the community and the symptoms described by the patient.

Source: http://www.cdc.gov/flu/about/disease/symptoms.htm

5. For adults ≥18 years old with ILI, advise the person to go to an emergency department if he/she has any of the following (http://www.cdc.gov/flu/takingcare.htm)

   • Difficulty breathing or shortness of breath

   • Pain or pressure in the chest or abdomen

   • Sudden dizziness

   • Confusion

   • Severe or persistent vomiting

   • ILI symptoms that improve but then return with fever and worse cough

6. For children 2- <18 years old with ILI, advise the person to go to an emergency department if he/she has any of the following (http://www.cdc.gov/flu/takingcare.htm)

   • Fast breathing (See Appendix A) or difficulty breathing or chest pain

   • Bluish skin color

   • Not drinking enough fluids

   • Not waking up or not interacting

   • Being so irritable that the child does not want to be held

   • ILI symptoms improve but then return with fever and worse cough

   • Fever with a rash

7. If the person has ILI and is a pregnant woman and has any of the following, she should call 911 right away:

   • Difficulty breathing or shortness of breath

   • Pain or pressure in the chest or abdomen

   • Sudden dizziness

   • Confusion

   • Severe or persistent vomiting

   • High fever that is not responding to Tylenol® (acetaminophen or store brand equivalent)

   • Decreased or no movement of your baby

4. If the patient’s signs and symptoms don’t meet the ILI definition, he/she may have an atypical case of influenza, or may have an illness other than influenza.

Assess for acuity per usual protocol (including underlying chronic medical conditions – See Section 5. Assess Patients with ILI for High Risk Conditions) and refer to primary healthcare provider (HCP)/medical home as needed. See Section 8. Referral to Medical Provider

1. NOTE: use clinical judgment, a patient who is ill and is pregnant/recently pregnant (post-delivery within 2 weeks), has an underlying medical condition or is <5 or ≥65 years old may benefit from an evaluation by a medical provider. If patient does have influenza, antiviral treatment is recommended as soon as possible for patients in these groups who are at high-risk for complications.

2. Refer to primary healthcare provider/medical home if patient is worried or you are uncertain about acuity or etiology of symptoms. See Section 8. Referral to Medical Provider

3. If unsure about how to manage this patient consult Medical Director for guidance.

4. Patients <5 years old or ≥65 years old with influenza may not have signs/symptoms that meet the ILI definition (typical influenza symptoms are less common in young children and fever may not be present in the elderly)

   • However, the very young and old are at higher risk for flu complications because of their age and any underlying conditions.

   • Use clinical judgment in evaluation and recommendations.

   • Even if their signs and symptoms do not meet the ILI definition, they may benefit from an evaluation by a medical provider; if unsure about how to manage, consult Medical Director for guidance.

5. Patient education for those ill but not meeting the ILI definition and NOT referred to a provider:

   • Should symptoms worsen or if the patient or caregiver has further questions or concerns about the patient’s health, they should be advised to call their primary care provider/medical home or seek medical care at an urgent care facility or ED.

5. Assess Patients with ILI for High Risk Conditions

   1. “Please tell me about any medicine that you/sick person take(s) regularly.” Ask about current medications that might indicate underlying chronic conditions

   2. Does the patient live in a nursing home or other long-term care facility? (If Yes, refer to onsite medical care provider and do not proceed further with triage)

   3. “Do you (or the sick person) have/has any ongoing medical conditions?”

   4. IF CALLER SAYS “Yes”, note the condition.

   5. IF CALLER SAYS “No”, “Let me quickly review some categories of medical conditions, to be sure. Does the patient have any of the following medical conditions? (read category names and provide further descriptions if caller needs more info)...”

      • Chronic pulmonary disease including asthma or COPD (bronchitis or emphysema) or conditions associated with impaired pulmonary function or the handling of respiratory secretions or that can increase the risk for aspiration (e.g., cognitive dysfunction, spinal cord injuries, seizure disorders, or other neuromuscular disorders)

      • Heart condition or surgery (except uncomplicated high blood pressure) – congestive heart failure, history of coronary artery disease, heart attack, heart surgery or procedures (such as stent placement or bypass), blood thinners or other meds due to heart arrhythmia (excluding hypertension)

      • Significant kidney and liver disease as defined by your doctor. Patient has been told to avoid or reduce the dose of medications because of liver or kidney disease, or is under treatment for liver or kidney disease

      • Diabetes, metabolic or endocrine disorders (e.g., diabetes mellitus)

      • Blood disorders (e.g., sickle cell disease)

      • Neurological and neuromuscular disorders [including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy (seizure disorders), stroke, intellectual disability, moderate to severe developmental delay, muscular dystrophy, or spinal cord injury].

      • Compromised immune system (immunosuppression) (e.g., seeing a doctor for cancer and treatment such as chemotherapy or radiation, received an organ or bone marrow transplant, taking high doses of corticosteroids [or equivalent dose of another steroid], HIV or AIDS)

      • Current or recent pregnancy (ask if patient is female and 12 years and older. Does the patient say she is pregnant, receiving care for pregnancy, thinks she might be pregnant, or is within two weeks postpartum (including following pregnancy loss)? Ask if patient has had any complications of pregnancy such as hypertension in pregnancy, gestational diabetes or other conditions.

      • American Indian and Alaskan Native

      • Morbid obesity: Would they call themselves significantly overweight? If so, how much do they weigh? Ask patient for their height. (See morbid obesity table in Appendix A.)

      • Source: http://www.cdc.gov/flu/about/disease/high_risk.htm

   6. If the patient has ILI and is 5-64 years old and has none of the high risk conditions above, assess for acuity per usual protocol and skip to Section 7. No High Risk Conditions with ILI

   7. If the patient has ILI and is <5 years old or ≥65 years old and/or has any of the high risk conditions above, assess for acuity per usual protocol and proceed to Section 6. Patient has ILI and is <5 or ≥65 years old or Has a High-Risk Condition

6. Patient has ILI and is <5 or ≥65 years old or Has a High-Risk Condition

   1. Explain that the symptoms they are experiencing may mean they might have influenza (but only an influenza test (testing respiratory specimens for influenza viruses) can tell for sure).

   2. Although you cannot confirm they have the flu over the phone, the caller needs to know that the patient’s medical condition and/or age may make it more likely that they will get complications from the flu, like pneumonia.

   3. The flu also can make long-term health problems worse, even if they are well managed. EXAMPLES:

      • People with asthma, COPD, chronic congestive heart failure or coronary artery disease may experience worsening of their conditions.

      • For people with diabetes (type 1 and 2), their immune system may be less able to fight the flu. Also, flu illness can raise blood sugar levels.

   4. Explain that because they have symptoms of the flu and have a medical condition (or are under 5 or over the age of 65 years): “The _______________ Health Department and the Centers for Disease Control and Prevention (CDC) recommend that people who have a high risk condition and have flu symptoms should contact their healthcare provider for advice as soon as possible. Remind your provider/doctor’s office about your high risk status for flu.”

   5. For children <18 years old

      • If child <5 years old: “Children who are younger than 5 years old commonly need medical care because of influenza; even children in this age group who are otherwise healthy are at risk for complications of influenza , simply because of their age.”

      • If child ≥5 years old: “Children and teenagers who have medical conditions like <name of condition that child has> commonly need medical care because of influenza.”

Source: http://www.cdc.gov/flu/protect/children.htm

6. Explain that you cannot be sure that they have the flu, but if they do, the flu can be treated.

   • “Your healthcare provider will determine whether influenza testing and treatment are needed. It is important that you see a medical provider as soon as you can so they can determine if you/they have influenza and if you need any treatment or medicine. Remind your provider/doctor’s office about your/sick person’s high risk status for influenza.”

   • If caller asks about medicines that are prescribed to treat influenza, “If a prescription for antiviral drugs is given by a doctor, the antiviral medication should be given as soon as possible because they work better for treatment the sooner they are started.”

   • “When used for early treatment (and given within 2 days of the illness starting), prescription antiviral drugs can lessen symptoms and shorten the time a person is sick with by 1 or 2 days. They also may prevent serious influenza complications, like pneumonia. For people with a high risk medical condition, early treatment of influenza with an antiviral drug can mean the difference between having milder illness instead of very serious illness that could result in a hospital stay.”

7. Source: http://www.cdc.gov/flu/antivirals/whatyoushould.htm

8. Emphasize that because the sick person has a condition that may make them at higher risk for complications from influenza, the caller should contact a healthcare provider or see a medical provider for advice as soon as possible!

9. See Section 8. Referral to Medical Provider

1. Patient Has ILI but No High Risk Conditions (Based on above triage, patient has signs and symptoms of ILI but no underlying high risk conditions.)

   1. Explain to the patient/caller:

      • Although you cannot confirm the patient has influenza over the phone, they do have symptoms that are common for people who have influenza.

      • Explain that the symptoms they/sick person is experiencing may mean they may have influenza (but only confirmation by an influenza test can tell for sure).

      • “Most people with the flu have mild illness and do not need medical care.”

      • “If you/sick person are (is) very sick or if you (caller or patient) would like to see a healthcare provider, if you are worried about your/sick person’s illness, or wish to discuss with your doctor, I encourage you to contact your usual healthcare provider (doctor, nurse practitioner, physician’s assistant, etc.) for advice.”

      • “Your healthcare provider will determine whether you/sick person need(s) to come to the office/clinic for an appointment and whether influenza testing and antiviral treatment are needed.”

      • Uncomplicated influenza illness typically resolves after 3–7 days for the majority of persons, although cough and feeling tired can last for >2 weeks. However, early (within 2 days of the start of symptoms) antiviral treatment can reduce the duration of symptoms.

      • Advise that if the patient’s symptoms worsen, they develop new symptoms, or they do not feel better in 2–3 days, they should immediately seek care with a medical provider.

   2. Source: http://www.cdc.gov/flu/takingcare.htm

   3. IF NEEDED – See Section 8. Referral to Medical Provider

   4. See Section 9. Patient Teaching/Information

8. Referral to Medical Provider

   1. Ask if they (or the patient) have a regular doctor, healthcare provider, or clinic that they call or go to for medical care.

      • If they do, recommend that they call their doctor/provider today (or as soon as possible if not during business hours). If after normal office hours, advise to contact their provider as soon as possible and immediately if the person’s symptoms worsen. “Remind your provider/doctor’s office about your/sick person’s high risk status for influenza.” Their provider can give them advice over the phone or make an appointment to see them as soon as possible.

      • If they do NOT have a usual provider, use the VISIONLINK database to provide information to the caller about medical providers and/or community clinics (NOTE: provide the contact information for two medical providers, if available) that are close to them (based on their zip code)

        1. If after normal office hours, advise to contact a provider as soon as possible and immediately if the person’s symptoms worsen. “Let the provider/doctor’s office know about your/sick person’s high risk status for flu.”

        2. Be sure to let the caller know whether the provider/clinic accepts walk-in patients or if they have to call ahead for an appointment since they need care as soon as possible.

        3. Also tell the caller the days and hours of operation of the office/clinic, phone number, address, any documents that they may need to bring with them, and information about sliding scale and payment methods (for example, if they take Medicaid or Medicare).

        4. If the caller is a Spanish-speaker, let them know if the clinic also serves Spanish-speaking patients.

2. If caller has problems with transportation to medical care, and has ILI and a high risk condition, use VisionLink database to search for available services (based on where the patient lives)

3. For callers who are unsure if they will seek face-to-face care, advise them to call their provider first, and if they need to go to the doctor/clinic, then advise them to call 2-1-1 to get information about available transportation services. <NOTE: Do not refer caller back to Flu on Call™ for this information>.

4. See Section 9. Patient Teaching/Information

9. Patient Teaching/Information

   1. Advise that a sick person with influenza needs to stay home and avoid contact with others except to get medical care.

      • When the sick person goes out of the house to get medical care, advise that they wear a facemask (if they have one), and cover coughs and sneezes with a tissue. Remind them that the sick person should wash their hands often to keep from spreading influenza to others.

      • “CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or other necessities. Your fever should be gone without the use of a fever-reducing medicine, such as Tylenol® (acetaminophen). You should stay home from work, school, travel, shopping, social events, and public gatherings.” Source: http://www.cdc.gov/flu/takingcare.htm

   2. If desired, use over-the-counter preparations to reduce fever as needed, per package instructions.

   3. Advise caller DO NOT give aspirin to any person < 19 years old with suspected or confirmed influenza because of the risk of developing Reye’s syndrome.

   4. Advise that if the patient’s symptoms worsen, they develop new symptoms, or they do not feel better in 2–3 days; they should immediately seek care with a medical provider.

   5. Advise get immediate medical care if the sick person experiences:

      • Difficulty breathing or shortness of breath

      • Purple or blue discoloration of the lips

      • Pain or pressure in the chest or abdomen

      • Sudden dizziness

      • Confusion

      • Severe or persistent vomiting

      • Seizures

      • Flu-like symptoms(http://www.cdc.gov/flu/consumer/symptoms.htm ) that improve but then return with fever and worse cough

Source: http://www.cdc.gov/flu/consumer/caring-for-someone.htm

6. Other information about home care is available in Appendix B.

7. If caller has other social or non-medical problems (such as financial problems, and can’t pay rent, needs food or shelter, etc.) advise them to call 2-1-1 after they contact their medical provider, to get information about available services. Do not refer caller back to Flu on Call™ for information about these services.

8. NOTE: Based on your Center’s usual protocol and/or guidance from your Medical Director, consider follow up calls to any patient advised to contact their provider after the call to ensure that they sought medical advice, assess if their condition has improved or worsened, and to determine final disposition.

10. Coding Influenza Calls

    1. [See NPDS coding manual for further guidance]

    2. Caller Information: Name, phone number, city, state, zip code

    3. Patient Information: Name, age, weight, prior medical history, allergies, current medications

    4. Document in Case Notes: History of the illness, signs/symptoms, allergies, medical history, current meds, your assessment, and include disposition in treatment plan as determined by medical management guidelines

    5. Management Site: Document if the patient is advised to call 9-1-1, seek medical care at an ED, seek medical care at an outpatient office or clinic, advised to contact their provider, or treated at home.

    6. Substance Verbatim/Generic Code:

    7. CDC Drill product code: Micromedex Emergent Product Code # 75 (6931368): Use (6931368) for ALL exposure and information simulated drill exercise calls

    8. Influenza Pandemic product code: Micromedex Emergent Product Code # 74 (6930188): Use BOTH (6930188 and 6931368) for simulated ILI calls

    9. Exposure Site: Unknown

    10. Reason: Environmental Note: Occupational if contracted as a direct result of work

    11. Clinical Effects: code per NPDS guidelines based on symptoms provided by patient/caller

    12. Medical Outcome: Code all exposure calls as “confirmed non-exposure” for this Demonstration Project

Disclaimer

These guidelines are designed only to assist physicians and those under their supervision who work in selected poison control centers in identifying indicators of and responses to flu-like symptoms in adults for the 2016 Flu on Call™ Demonstration Project, for a limited system pilot test. It does not provide guidance for other medical conditions nor is it intended to substitute for professional medical advice. This guidance is meant to augment existing medical triage protocols used by poison center staff by including information about patient management of influenza-like illness. These protocols may not represent future pandemic influenza guidance published by the Centers for Disease Control and Prevention (CDC). Additionally, these guidelines are developed by the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention, the Agency for Toxic Substances and Disease registry, or other institutions with which the authors are affiliated.

Appendix A: Look up Tables for Fast Breathing and Morbid Obesity

Definition of “Fast Breathing”

Age	Respiratory Rate
Birth up to 3 months	>60/min
3 months up to 1 year	>50/min
1 to < 3 years	>40/min
3 to < 6 years	>35/min
6 to < 12 years	>30/min
12 to <18 years	>20/min

Source: http://www.cdc.gov/h1n1flu/clinicians/pdf/childalgorithm2.pdf

Definition of “Morbid Obesity”

Body mass index (BMI) is a measure of body fat based on height and weight.

Morbid obesity is defined as a BMI greater than or equal to 40.

See table below to determine the weight for a given height that will equal a BMI of ≥40.

Please note that weight above this amount for a given height will yield a higher BMI.

Morbid Obesity Table (BMI ≥ 40)

Height (ft. - in.)	Body Weight in pounds = BMI of >40
4-10	>191
4-11	>198
5-0	>204
5-1	>211
5-2	>218
5-3	>225
5-4	>232
5-5	>240
5-6	>247
5-7	>255
5-8	>262
5-9	>270
5-10	>278
5-11	>286
6-0	>294
6-1	>302
6-2	>311
6-3	>319
6-4	>328

Source: Adapted from http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.pdf

Appendix B: Home Care Education

Steps to Take if You Get the Flu

1. If you get very sick, are pregnant, or are 65 years or older, or are otherwise at high risk of flu-related complications(http://www.cdc.gov/flu/about/disease/high_risk.htm), call your doctor. You might need antiviral drugs to treat flu.

2. Stay at home and rest.

3. Avoid close contact with well people in your house so you won’t make them sick.

4. Drink plenty of water and other clear liquids to prevent fluid loss (dehydration).

When caring for people who have the flu:

• Avoid being face to face with the sick person. If possible, it is best to spend the least amount of time in close contact with a sick person.

• When holding sick children, place their chin on your shoulder so they will not cough in your face.

• Wash your hands(http://www.cdc.gov/handwashing/) often and right way.

• If soap and water are not available, use an alcohol-based hand rub.

• Make sure to wash your hands after touching the sick person. Wash after handling their tissues or laundry.

Get immediate medical care if the sick person experiences:

• Difficulty breathing or shortness of breath

• Purple or blue discoloration of the lips

• Pain or pressure in the chest or abdomen

• Sudden dizziness

• Confusion

• Severe or persistent vomiting

• Seizures

• Flu-like symptoms(http://www.cdc.gov/flu/consumer/symptoms.htm) that improve but then return with fever and worse cough

Source: http://www.cdc.gov/flu/consumer/caring-for-someone.htm

Appendix C: CDC Resources and References for Influenza

1. Flu Symptoms & Severity http://www.cdc.gov/flu/about/disease/symptoms.htm

2. Clinical Signs and Symptoms of Influenza (Influenza Prevention & Control Recommendations) http://www.cdc.gov/flu/professionals/acip/clinical.htm

3. People at High Risk of Developing Flu-Related Complications http://www.cdc.gov/flu/about/disease/high_risk.htm

4. Influenza Antiviral Medications: Information for Health Care Professionals http://www.cdc.gov/flu/professionals/antivirals/index.htm

5. FDA Approves Rapivab to Treat Flu Infection. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm427755.htm December 22, 2014

6. Antiviral Agents for the Treatment and Chemoprophylaxis of Influenza http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6001a1.htm

7. “Pink Book” Chapter on Influenza http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/flu.pdf

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D74, Atlanta, Georgia 30333; ATTN: PRA (0920-1026)

pg. 14 For Use Only by Poison Centers during 2016 Flu on Call™ DEMONSTRATION PROJECT